, 2007) (see 29).. Constraint-induced moveme nt therapy in children with hemiparesis Constraint-induced movement therapy has not been studied in CP nearly to the extent it has been in adults with stroke, nor is the level of evidence of efficacy (Sackett level) nearly as strong. Based on our own findings concerning practice effects in children with hemiplegia (see above), we began to modify CIMT for use in children with hemiplegic CP in the late 1990s. In a preliminary study (Charles et al.

, 2001), we examined the efficacy of modified CIMT in three children (age 8, 11 and 13 years) with hemiplegic CP in the home environment. Children donned a cotton sling with the distal end sewn closed on their non-involved upper extremity for 6 hours per day for 14 days. During these 6 hours, they were engaged with a trained interventionist in a variety of child-friendly functional and play activity requiring unilateral use of their involved upper extremity.

The children showed improvements in unilateral motor performance as measured by a standardized test of timed motor activities (Jebsen Taylor Test of Hand Function), as well as both temporal and force coordination during grasping (Charles et al., 2001). These initial findings were promising, and drove our subsequent development (Gordon et al.

These latter studies were provided in a day camp setting with two to four children in each session. In one study (Charles et al., 2006) children (ages 4 8 years) were randomized to receive 2 weeks (10 consecutive weekdays) of CIMT or no additional treatment (both groups continued to receive their usual and customary care).

Significant improvements were noted in movement efficiency and functional limitations (standardized and criterion referenced tests of upper extremity and hand function) and environmental functional limitations (caregiver report). An example of these improvements can be seen in Figure 31.2, which shows that children in the intervention group improved more than children in the no-treatment control group on the Jebsen Taylor Test of Hand Function 1 week after the intervention.

The decrease in time for the intervention group was maintained over the 6-month follow-up period. Interestingly, in this small randomized control trial we found that severity of hand function and attention significantly predicted improvement, with children who were more mildly to moderately affected and had better attention improving the most. In a subsequent study (Gordon et al.

, 2006b) we showed similar gains in 9 13-year-old children. There is a growing number of studies of forced use (Willis et al., 2002) and CIMT (Eliasson et al.

NET ime to complete the six timed items (writing excluded) of the Jebsen Taylor Test of Hand Function for the constraint induced movement therapy (CIMT) (solid line) (n 11) and control (dashed line) (n 11) groups at each testing session. Faster times correspond to better performance. The maximum allowable time to complete each item was capped at 120 s, resulting in a maximum score of 720 s.

Modified from Charles et al. (2006)..

and intensity of treatmen t (ranging from usual and customary care schedules to adult models of CIMT), restraint (gloves, mitts, slings and casts) and outcome measures. While the evidence is not yet conclusive, all of these studies have reported positive outcomes. While it has been claimed that greater improvements are seen using the more intense models with a cast worn continuously for 3 weeks (Taub et al.

, 2007), there are two lines of evidence against these claims. First, these authors are unable to compare their outcomes to the other studies, as their outcome measures are all self-designed (with no validity or reliability studies) and largely rely on perceptions of caregivers. Second, positive outcomes using standardized measures have been reported using far less restrictive restraints (mitts) during just 2 hours per day (Eliasson et al.

, 2005). In a recent study we administered 2 weeks of CIMT to 8 children with hemiplegia (ages 5 13 years) for 6 hours per day, and then re-administered the intervention 12 months later (Charles & Gordon, 2007). As seen in Figure 31.

3, time to complete the Jebsen Taylor test of Hand Function significantly decreased after the initial intervention, with the improvement maintained 12 months later. Following the second dose of CIMT, a similar decrease in time occurred. Given that children benefit from repeated bouts of CIMT (Charles & Gordon, 2007), there is no advantage to maintaining the potentially invasive schedule and restraints (see below), and instead, one could administer CIMT through repeated, and less intensive, bouts.

. Limitations of CIMT Despi Data Matrix barcode for .NET te the promise of CIMT, there are several conceptual problems in applying it to children. First, CIMT was developed to overcome learned non-use in adults with hemiplegia.

These adults lost upper extremity function as a result of their condition, and may be motivated to regain previously learned functional behaviors. In contrast, children with.